Public Health Service Rationing for Elective Surgery in New Zealand: 2004-2007

The New Zealand health system is two-tiered with elective treatments are performed by both publicly funded state hospitals and by private hospitals. Publicly funded operations are rationed using a prioritisation system which was introduced in 1998 to curtail expanding waiting lists for elective surgery. One of the aims of the new booking system was to generate national tools for prioritising patients in order to improve the equality of access to public elective surgery throughout New Zealand. However, priority scoring systems were not implemented in a consistent manner and access to elective surgery remains very unequal. Despite large media attention and a high public profile, waiting times have attracted little research in medical geography or within the wider social sciences community. The subject has been partly reserved for public health commentators within the medical field, who have found that variation in waiting times has much to do with the referral practices of physicians, the management of waiting lists by District Health Board (DHB) staff and the amount of private practice that occurs within each district. Most notably several studies have identified that in areas associated with high private admissions, patients tend to suffer higher waiting times for the same procedures in the public hospital system. This study examines the performance of the New Zealand Booking System (NZBS) during the years 2004 to 2007 to assess the equitable delivery of publicly funded elective surgery procedures. Waiting times (NBRS) and admissions (NMDS) datasets were sourced from the New Zealand Health and Information Service (NZHIS) of The Ministry of Health. Mean and Median waiting times were compared spatially between each of New Zealand’s 21 DHBs, compared with Australian waiting times and then broken down into five common medical specialties. Waiting times were then analysed by ethnicity, level of material deprivation and other individual factors using data from the 2006 New Zealand Census. Finally, rates of admissions were calculated for the public and private hospital sectors during the study period. These were used to correlate waiting times results with the amount of private practice in each DHB. ACC cases were extracted from the dataset to avoid bias in waiting times as much of this work is contracted out to the private sector and not subject to lengthy waiting times for treatment. A number of medical specialists and hospital administrators were interviewed to discuss results, explain prioritisation tools and management practices. Results showed large variations in the median waiting times of New Zealand DHBs. A north south gradient is observed in which southern DHBs suffer longer waits for care. Vastly better results were observed for Australian public hospitals than those seen in New Zealand. For waiting times as determined by individual factors, Maori and Pacific Island patients and those from lower socio-economic backgrounds suffered longer waiting times nationwide although, in certain DHBs inequalities for access to elective surgery were exacerbated. However, ethnic differences were more pronounced than socio-economic variations. Admissions results showed significant positive correlations between the amount of private practice and the waiting times experienced in each DHB which are supported by previous research. Feedback from interviews confirmed inconsistency in the use of scoring tools, manipulation occurring on behalf of the DHB management to achieve performance goals set by the Ministry of Health and provided some further explanation of the other quantitative results. Access to elective surgery is determined partly by location of residence, ethnicity, deprivation and where hospital resources are located but most importantly by the willingness to pay for treatment within the private hospital sector and the ability to manipulate the public prioritisation system